1. Regional Conference of Sector Network Health & Social Protection Africa, MENA and LAC 6-9. May 2014 | La Palm Hotel, Accra/Ghana Towards UHC in Burundi – How to argue for “more” money ? Simin Schahbazi | Burundi

2. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC Towards UHC in Burundi – Role of domestic funding ?? 1)Government investment in health 2)Who funds health in Burundi ? 3)Who is covered ? 4)On the way to UHC ? 5)Steps on the way to UHC 6)Innovative funding mechanisms 7)Challenges for dedicating domestic resources to health

3. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC 10% of Government budget allocated to the health sector (2012) GOVERNMENT INVESTMENT IN HEALTH NOT REACHING ABUJA TARGET The health sector is increasingly dependent on donor funding

4. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC WHO FUNDS HEALTH IN BURUNDI? Total health expenditure by source (2010) THE per capita: 29 USD(2010); 26 USD (2012) THE as % of GDP: 12% (2010), 9% (2012) Share of household contribution decreased from 38% (2007) to 28% (2012) BUT: still serious equity concern as catastrophic health expenditures limit access for the poorest groups: 123 persons are pushed into poverty every day

5. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC 50% of Burundians are covered by some health insurance scheme schemes contribute to only 17% of THE (2012) Insufficient and fragmented coverage CAM (Public medical insurance): 20%, indigents: 1%, CBHI: 2%, Civil Servants: 6%, PHI: 1%, gratuité/PBF: 20% Schemes are highly underfinanced (CAM + indigents!) Hospitals increasingly indebted WHO IS COVERED?

6. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC ON THE WAY TO UHC ? Lessons learned from international experiences: Political will regarding UHC  Sufficient investment in health: most of the schemes are highly underfinanced  Progressive process: PBF OK but not CAM  Minimizing fragmentation and enhance equity in pooling: high fragmentation  Reform is including demand and offer of health services: quantity & quality ! CAM: accelerator to achieve UHC ? Strong political will (MOH), high coverage potential of informal sector if mandatory Political debate: Assistance médicale vs. Assurance médicale Indigents? 15-20% → subsidizing premiums ! (solidarity fund GOT+PTF ?)

7. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC Since 2011: UHC Vision Recommendation of the health sector Revue Recommendation of the revue PBF/gratuité Situation Analysis started in Sep 2013; finalized in April 2014 Validation workshop with GOV, PTF, CS including reflections on on strategy options First draft of strategy 2014 ? - Institutional arrangements - Upcoming presidential elections 2015 !

8. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC INNOVATIVE FUNDING MECHANISMS DISCUSSED IN BURUNDI ? Diverting existing domestic resources to UHC CAM, MFP Commitments to HIV/AIDS, malaria, TB (mostly Global Fund ) Commitments to multilateral health programmes (e.g. GAVI for vaccination) Creating new sustainable funds for UHC Taxes on harmful products: decision décember 2013 → beer tax (CAM) Taxes on tabacco are discussed … ? Introducing efficiency and effectiveness PBF Collecting taxes and insurance contributions more efficiently Reduction of fragmentation in pooling to expand redistributive capacity of prepaid funds Improving financial management Avoiding double payments (gratuité)

9. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC CHALLENGES FOR DEDICATING DOMESTIC RESOURCE TO HEALTH UHC is theoretically priority on political agenda, BUT  Inadequate institutional arrangements hinder the commitment for domestic financing Financial constraints: GDP 260 USD/capita (2012) Challenges: macroeconomic constraints, poverty, galloping demography Scope of action to maximize fiscal space is not very high but existent: Sources for extent of fiscal spaceScope of action Macroeconomic conditionslimited Efficiency gainshigh Changing budget prioritiesvery high Mobilize external financial assistancevery high

10. Regional Conference of Sector Network Health & Social Protection Africa, MENA and LAC 6-9. May 2014 | La Palm Hotel, Accra/Ghana simin.schahbazi@giz.de THANK YOU!

11. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC DimensionCAM IndigentsCBHI (MCS)Civil Servants (MFP) PHI Coverage ? beneficiaries (25-30%) < 1% 175,000 beneficiaries (≈ 2%) 35 MCS 200,000 employees = 1.2 Mill beneficiaries (≈ 8%) < 0,5% Market segment Poorer segment of informal + rural sector (≈2/3 % of the population) Poorest segment of informal + rural sector ≈20 % of the population Informal + rural sector (≈2/3 of the population) Formal sector Functionaries, Police, Military, students, Formal sector (Private) Employees Non Professional health risk ≈ 140,000 employées (6%) Enrollment Voluntary Mandatory Voluntary Collection Remit to HC ONG buys card at HCRemit to CBHIRemit to MFPRemit to PHIs Premium range 2 USD/hh/year 2014: 4 USD/hh/year 100 % cost recovery by MSNDPHG, communes, ONGs 6 USD – 25 USD/hh/year Depending on scheme 10% of salary 4% employee 6% employer 5-15 USD/month Benefit package Medium range≈ CAM Primary & partially Hospital care Broad range Depending on contracting part (PHI, micro insurance) Provider payment Fee for service 20% co payment Fee for service Capitation 20% copayment Capitation 20% co payment Fee for service 30-40% co payment

12. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC PBF/gratuité 2006: exemption of user fees for pregnant women (delivery, services)& children<5 2010: scaling up performance-based financing (PBF) schemes into a national mechanism → Strategy: linking the PBF approach with user fee exemptions Advantages: formalized channel for replacing the revenue from user fees at the facility level (incl. verification/validation system) incentives for increasing quantity and quality of care → counterforce for the demotivation of health workers Reducing administrative burden GOT commitment (annual 1.4% of GGE) Weakness: Pervers effects and frauds Problems of quality measuring Overlap witch other mechanisms Underestimated prices for some indicators (delivery: 40USD) Incertitude of PTF funding  Coverage: ≈ 20 %  utilization of health services in Burundi has continued to increase → strategy contributes to MDG 4 and 5  BUT: PBF transforming into a simple financing mechanism of the «gratuité »  Financing gap: 8 mill USD (2013)  Critical situation in raising number of hospitals → demotivation → Quality ↓

13. Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC Since 2011: UHC Vision Recommendation of the health sector Revue Recommendation of the revue PBF/gratuité Situation Analysis started in Sep 2013; finalized in April 2014 Validation workshop with GOV, PTF, CS including reflections on on strategy options First draft of strategy 2014 ? Upcoming presidential elections 2015 ! 4 options for a strategy (non-exclusive): 1)Maintain of schemes + compulsory insurance formal sector + solidarity fund (indigents) 2)2 schemes (formal, informal) + extended CAM+ + solidarity fund (indigents) 3)Scheme formal sector (compulsory)+ Extended CBHI – (Rwandian model) 4)Unique mechanism of SHP (Ghanian model)